10 May 2010

There are times when you don't quite want to go see the next patient in the queue. You scan the chief complaint and visit list, look around as if to say "aren't there any other doctors here who can take care of this for me?" And then, because it's your inescapable fate, you pick up the chart, square your shoulders, and walk into the room.

The patient was a young lady with pelvic pain. She had moved up from Texas one month ago, and had already been to our ER six times for this complaint of pain. She was a complex patient with a history of a gynecologic malignancy (reportedly -- nobody had ever been successful in getting records from Texas) and she suffered from pain related to this history. Only Demerol worked to treat her pain (she had been quite shocked to learn that we don't use Demerol, but quickly adapted to Dilaudid instead). She had not yet established care with a primary care doctor or a gynecologist. The imaging studies in our ER had been unremarkable. So it appeared that she was here for pain medicine again with no change in her symptom complex.

These cases are challenging for an ER doc. You can take the easy road and just give 'em some pain meds and send them away, but that more or less guarantees they will be back for more pain medicine. Or you can take the hard road and send them away with nothing, but that can be really hard, and there's a risk you're undertreating someone with real pain, and they'll probably be back anyway and you'll get a complaint to boot. There's no win here -- either way this is not a problem amenable to fixing in the ER.

But there was a twist with this young lady: she told me right up front that she had just been seen in the ER at St Mugworts Hospital, the suburban place directly to the north of our somewhat larger suburban place. She'd been there before too, but this time, she said that they had told her that since she had been getting her care at our hospital, she needed to come back here so "her doctors" could take care of her. As proof, she handed me the discharge instructions from Mugworts, slightly crinkled from her purse. Sure enough, they were dated and timed about two hours ago, and they read "Go to The Big Hospital in (our town) for your gynecologic care."

I was pretty stunned by this. I had never seen an ER doc so brazenly execute a patient dump. I clarified with her that she did not have a doctor at our hospital, just the ER docs she had seen, and that she had informed the ER doc at Mugworts of that fact. I couldn't resist -- I was so angry -- so I called the ER at Mugworts and asked to speak with Doctor Loser, who had sent her to us. That was a fun conversation. He must have been so pleased with himself at neatly getting a problem patient out of his ER, and he so clearly had not expected to be called on his little maneuver. I was clear with him -- I asked him if he had obtained an accepting physician before transferring this patient to our hospital (this immediately informed him that it was an unfriendly conversation and carried a threat of an EMTALA violation). He hemmed and hawed and said that he had just suggested that it was an option for the patient to go to Our Town. I pointed out that his documentation had been fairly direct, and asked what capacity we had that his hospital did not, and he waved his hands (metaphorically speaking) about the patient possibly needing emergency gynecologic surgery and our doctors knowing her better, but I was having none of that -- I pointed out that she had told him that our GYN surgeons had not seen her, and that he should have consulted his gynecologists about this patient, if he thought she might need emergency surgery. At this point, backed into a corner, the ER doc played on what he thought would be my sympathies, "Surely you agree that with chronic pain it's in the patient's best interest to be treated at a single facility." True that. No doubt. Once the patient is in your ER, I countered, she is your responsibility. You manage her pain, or you say no. You don't ship her (without notice or consent) to a neighboring facility.

At this point, I had the poor bastard wriggling in my grasp. I was not about to relent. I was pissed. "I am going to go take care of this patient now. As you and I both know, she does not need emergency surgery. She needs a pain management plan and I am going to work on one with her. And I am going to give Dr Jones a call about this inappropriate patient transfer in the morning." Dr Jones was the Chief of Staff at Mugworts; I happened to know him through legislative activity we had collaborated on before.

And I did -- he was appalled. What's more, at Dr Jones' suggestion, I wrote a very polite and carefully worded letter to the Mugworts Board of Directors. I explained that "I strongly feel that it is inappropriate to “dump” such a patient, either expressly or with a nod and wink, onto a neighboring facility. I believe that this episode would be considered with great concern by both state and federal regulators. I believe that a case could be made that this was a clear violation of EMTALA. Were I to report this to the relevant agencies, it would create significant administrative difficulties for St Mugworts Hospital and for Dr Loser. I view our relationship with Mugworts as one of neighbors and partners. It is therefore my hope that by providing you with this feedback, your Medical Quality Committee will have the opportunity to review the care provided, and take corrective action to prevent further inappropriate transfers between our facilities."

I am quite certain nothing "happened" as a result of this episode, by which I mean that Dr Loser is still working there and that he did not face sanctions or penalties as a result of his little trick. Which is fine -- I wasn't trying to get him fired. I suspect that he had to deal with some pretty unhappy emails and maybe explain himself at some administrative meeting, a painful experience. Maybe he got a slap on the wrist -- a verbal rebuke and some fluff for the record.

What I am equally certain about is that there is one doctor at St Mugworts who is never again going to try to dump a patient on The Big Hospital without calling us first and getting an accepting physician. Which is as it should be.

I'm no lawyer, so I can't say how far the "obligation" to report an EMTALA violation extends. In this case, I think Dr Loser would have an ironclad defense: the patient had been screened and found not to have an emergency condition. At that point, EMTALA has been fulfilled and he can release the patient to go anywhere. Also, they could have raised a defense that it wasn't a transfer. Thin, but legally defensible. So my assessment was that it was flirting with a violation but probably "legal" and that the treat of a report would probably accomplish as much as an actual complaint.

Shadow,Glad you did report. But why did you even suggest you would? I like to be stealthy. These people need to really vfib when confronted by the those on high. Of course that is, if anyone cares. He was probably just following the "other" protocol - which is not good for his license, but good for the facility.

In your post you say a case could be made that this is a clear violation of EMTALA. Not reporting a violation is a violation.

So if its a violation and you didn't report it you are as guilty as him.

EMTALA has no relevance once a screening exam has been ruled out and there is no emergency. So if this dumping doc did do an adequate screening exam and rule out an emergency he can unfortunately dump all he wants.

In this woman's case an adequate screening exam may have been a history and physical exam.

You can't have it both ways, accuse the dumper of violating EMTALA for dumping but then say you're off the hook because EMTALA doesn't apply.

I'll be honest, I dopn't get the point of this post and I'm not really sure why tearing the throat out of another ER Doc is at all useful. This young lady has a hopeless case with no answers, her malignancy story is probably bunk, she is addicted to narcotics, she's manipulative, she pushes everyones buttons. We all have a list of these patients in our ERs, they piss us all off, but directing that anger at each other doesn't seem all that useful either.I'm sure it felt good to tell off the other doc and try to mess up his career (that's what you're doing with these letters, right?) but to what end? Is the other doc really a loser, or is he just a busy guy like you trying to see real sick patients between the ones with made up stories and nonsense complaints and get through the day...

Its pretty lame to dump problem patients on another doctor. You say he's a busy guy blah blah blah. Well what do you think the docs are at the ER he directed her to?

I think the problem here though is that the narc dispensing needs to be nipped in the bud. Giving out narcotics for undiagnosed abdominal pain needs to stop. First visit, if you've given her a follow up doc to see maybe treat with narcs pending a possible diagnosis.

After that first visit and her opportunity for f/u, whether she's followed up or not, no further narcs from the ER.

Its kind of silly to tag the patient as a pain in the ass when we're the ones that are giving them narcs for repeated visits with complaints of pain. Then after 4, 5, or 6 visits all of a sudden we say no more narcs. We're the ones with the control here. We can say no as soon as we realize that they're chronic abdominal pains.

We're not doing these people any favors by enabling their drug addictions or treating whatever else is going on in their life that they're turning into abdominal pain with narcotics. And I think where we make a major mistake is to let it go on for a huge number of visits and then all of a sudden label them as drug seekers and cut them off. To be fair to them, we can't enable them for months, years and then all of a sudden cut them off.

This is not an EMTALA issue. The majority of your post outlines that this patient does NOT have an emergency medical condition, therefore EMTALA does not apply.

EMTALA has created lots of problems but can't believe the time and energy you spent in your misinterpretation of it. If you had spent that much time with the patient to direct her toward long term follow up your time would have been mucher better spent.

I agree with the last anon. You are the biggest boob of the two here. There are many reasons why going to one place is in the best interest of the patient:

1.) More likely to get a successful intervention and referral to proper primary management.

2.) prevent duplication of work up with unneeded and harmful radiation from tests.

3.) We all get annoyed with those who ER and doctor shop...the other ER doc is just calling her out on it.

EMTALA is a beast with many unsavory aspects. Wasting your time and getting your panties all bunched up trying to use EMTALA (wrongly)to harrass another ER doc is just about the biggest dumfugging thing I have ever heard of. All you really had to do was call the ER doc and inform him there was no established follow up at your place. As you wrote you were just pissed that you had to see the patient. The invoking of EMTALA and letter writing to the Chief of Staff solidifies you as holier-than-though sophmoronic dumbass.

Apparently loser doctor didn't want to see the patient any more than you did. A man to man phone call to discuss your unappreciation is fine. The EMATALA, letter writing stuff makes you the smug LOO-SAH!

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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